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2. Name
4. Address
5. Zip Code
7. Phone Number
8. Email Address
10. Time Discharge Discovered*
    Time Discharge Discovered

    Time Discharge Discovered
12. Date of Last Rain Event*
    Date of Last Rain Event Start Date

    —

    Date of Last Rain Event End Date
14. Estimated Quantity of Rain (In Inches)
16. Location of Discharge
    Please indicate nearby street intersections, addresses, and/or landmarks for reference.
18. Where Was Discharge Found?

    1. Open Ditch
    2. Stream
    3. Pipe Outfall
    4. Other
19. Was Water Flow Observed?

    1. Yes
    2. No
20. Was Flow Solid or Pulsing?

    1. Solid
    2. Pulsing
22. Was a photo taken?

    1. Yes
    2. No
23. If "Yes," please attach a copy to form
25. Odor

    1. None
    2. Musty
    3. Sewage
    4. Rotten Eggs
    5. Sour Milk
    6. Other
26. If you selected "Other," please write what it is:
28. Color

    1. Clear
    2. Red
    3. Yellow
    4. Brown
    5. Green
    6. Grey
    7. Other
29. If you selected "Other," please write what it is:
31. Clarity

    1. Clear
    2. Cloudy
    3. Opaque
32. Was there an oily sheen?

    1. Yes
    2. No
33. Was there garbage or sewage?

    1. Yes
    2. No
35. What else was present?
37. Additional Information to Assist in the Investigation
Leave This Blank:


39. 1. Receive an email copy of this form.
40. Email address

    This field is not part of the form submission.

41. Submit

* indicates a required field